By Paul Adriaanse, Annika Schepers and Jiska van Rijswijk
Introduction
According to the World Population Prospects [1]the world is ageing at an unprecedented rate (Image 1). Whereas 10% of people are aged 65 years or above in 2022, this number is believed to rise to 16% in 2050 [1]. Thus, the population of elderly individuals is not just increasing in absolute numbers but is also increasing proportionally to the working class population [1].
The ageing population comes with several problems and challenges [2, 3, 4], but one that is rarely ever mentioned is that in an ageing population there will be a larger share of elderly experiencing loneliness. It seems that loneliness increases with age. Among adults of 50 years and older, 19.3% report feeling lonely. For individuals of 65 years and older this has increased to 43.2% [5]. In addition to this, almost a quarter of the population aged 65 and older are considered to be socially isolated [6]. Therefore, because the proportion of elderly individuals worldwide increases, the odds are that the total number of elderlies that feel lonely or are socially isolated will also increase, posing a serious problem and challenge for society.
Image 1Projected distribution of the world’s population by age group
Note. Reprinted from “Projected world population distribution, by age group 2022-2100. “[7]
Note. Reprinted from “Projected world population distribution, by age group 2022-2100. “[7]
What exactly is meant by ‘loneliness’?
What exactly do we mean when we speak about ‘loneliness’? After all, almost all of us are alone for at least some period of time during the day. Does that mean we also feel ‘alone’, or ‘lonely’ every day? It does not necessarily. Loneliness is often described as a discrepancy between a person’s preferred level of social contact and their actual level of social contact [8]. This causes an unpleasant subjective state which we call loneliness [5]. Moreover, at least two subtypes of loneliness exist: Originally proposed by the sociologist Robert Weiss [9], loneliness is often split up into social and emotional loneliness [10 – 14]. Whereas social loneliness refers to a lack of feeling part of a social network, emotional loneliness refers to the absence of intimate relationships with some type of attachment figure, such as a partner [11, 15]. Studies have also found that these two subtypes are associated with different risk factors, providing empirical support for the legitimacy of the two subtypes of loneliness [10, 12, 13].
What are the consequences of loneliness?
As a set of feelings that stems from an absence of social and intimate needs [16], loneliness is linked to several poor mental and physical health outcomes [17]. Examples of poor health outcomes include fatigue, a decrease of cognitive functioning, and higher levels of depression [18 – 23]. Beyond that, a recent meta-analysis found that loneliness and a small social network size in elderly are even associated with higher mortality rates [24]. Taken together, loneliness is not only an unpleasant subjective state in itself but is also associated with various negative health outcomes. This makes it an even larger burden for elderlies themselves as well as society at large, due to an increase in health care expenditure, for example.
What are the causes of loneliness?
But why are elderly people so at risk of loneliness in the first place? This may have a lot to do with the sense of community that is so important to people, and which decreases as people get older. Some of the individuals that made up the community of elderly individuals pass away as everyone gets older, leading to a shrinkage in the size of the communities that elderly have. On top of that, elderly individuals tend to have lower activity levels. They meet less with the family and nonfamily members that they do still have [17], all resulting in less and less involvement in social communities.
Even though these findings give an idea about the bigger picture and the relationship between increasing age and loneliness, the causal mechanisms behind age and feeling lonely are not crystal clear in the scientific literature. While the relationship between age and loneliness is not linear, the idea has emerged that this relationship is rather curved as a “U”, suggesting that adolescents experience more loneliness than adults and elderly in society experience more loneliness than adults [15].
InterventionsSubgroups of lonely elderly
Although many intervention programs for tackling loneliness among older individuals have been studied over the years [30, 31], not many seem to take into account that not all elderly are equally capable of taking part in all kinds of interventions. Quite some variety exists in the fitness of elderly individuals: Whereas some elderlies are still capable of doing everything by themselves without any help needed, others are housebound, or even almost entirely reliant on the help of caregivers. Thus, since there is not a ‘single type’ of lonely elderly, one-size-fits-all interventions for addressing their loneliness either become relatively ineffective, or physically impossible altogether for many elderlies. We therefore propose different interventions for lonely elderly according to their individual fitness levels: Those who are able to leave their home on a regular basis, housebound elderly, and elderly that are completely unable to take care of themselves anymore (we will call them bedridden elderly from hereon).
Interventions for fit elderly
The elderly for which most interventions seem to be created are relatively fit elderly that are both cognitively healthy and able to leave their homes or perform fitness exercises [30, 31]. Since we saw in the introduction that the share of elderly, as well as the absolute number of elderlies, is likely to increase and that this may put more stress on the working population [2, 3, 4], interventions should neither be very costly nor be very time-consuming for others. Luckily, some researchers seem to have found a way to create effective interventions for decreasing loneliness that keeps these rules in mind: Technology-based interventions.
Technology-based interventions
In a systematic review and meta-analysis published this year, one of the most effective ways to decrease loneliness in elderly was through the use of technology [30]. Examples of using technology in interventions for decreasing loneliness include videoconferencing with family or trained interviewers and social internet based activities (SIBAs), which implies computer training that allows elderly to become included into internet-based societies and to support social online contacts [32, 33]. Thus, if elderly are already familiar with the use of computer-like devices and the internet, this enables care-givers to arrange relatively low-cost and low effort interventions that target loneliness in elderly by increasing social contact with family members or interviewers.
Interventions for reasonably fit elderly
Because some elderly people will have difficulties learning to work with online-tools, intervention programs should exist that do not require becoming familiar with such devices. Hence, we will now look at an intervention that may be more appropriate for this group of elderly people. This is an intervention with which some of you might already be quite familiar and which has also shown to be one of the most effective ways of decreasing loneliness in elderly: Pet ownership.
Pet ownership
According to the aforementioned systematic review and meta-analysis [30], simply being the owner of a pet is one of the most effective ways to decrease loneliness. When thinking about it, this should perhaps not actually be that surprising to us, since animals, and especially pet animals, share some characteristics with us humans. Thus, similar to human relationships, one of the most plausible reasons why pet animals could help reduce loneliness is that it may help humans gain an affectionate bond, or attachment to the pets [34, 35]. Originally proposed by Bowlby [36], attachment theory proposes that humans form strong emotional bonds with their children or romantic partners, which ultimately aids in their survival. Likewise, this attachment mechanism in humans may catch on to pet animals such as dogs, yielding various positive outcomes for humans such as decreasing loneliness [34, 37]. It is therefore not surprising that the relationship between humans and animals has a long history and shows itself in the large number of households worldwide that have a pet animal [34].
Now, when considering pet ownership as an intervention for decreasing loneliness among housebound elderly, two things should be noted. Firstly, most elderly individuals that are not fit enough to leave their homes will be unable to keep certain species of pet animals. For example, they may not be physically capable of walking a dog. In order for pet ownership to be a feasible intervention, the pet animal should be chosen according to the level of fitness of the elderly person in question. Secondly, if it is true that the mechanism by which pet ownership decreases loneliness is via attachment between the pet and the owner, pets that are most likely to create this attachment should be chosen. This may well depend on the preferences of the future owner: The animal with which the individual feels the most affection should be considered.
In conclusion, it makes sense that if a lonely elderly person owns a pet to decrease loneliness, the pet has to be chosen by the elderly themselves. In this way, the intervention will be feasible and the attachment between the human and the pet may be maximised.
Interventions for bedridden or immobile elderly
Since the vast majority of the interventions for which research has been conducted targets elderly that are relatively fit, a final group of the rather ‘unfit’ elderly is being left out. Not every elderly individual will still be able to either take care of a pet animal or work with relatively novel technology. Luckily, at least one intervention exists for this group of lonely elderly that does seem feasible, and also happens to require low effort from the working population and is relatively uncostly: Telephone befriending.
Telephone befriending
Telephone befriending is a way in which individuals – typically volunteers – have relatively short phone conversations with elderly that last around 20 minutes [38]. Although not much research has looked into the effectiveness of telephone befriending, at least two studies showed promising results [38, 39]. In the first study, researchers held 40 in-depth interviews with elderly and volunteers in which the elderly were asked about their experiences with telephone befriending [38]. The elderly indicated that the benefits of the intervention included less lonely and anxious feelings, improved well-being and quality of life, an improvement of their emotional and physical health, and the feeling that they are not forgotten and that they belong [38].
A second study compared two groups of older participants: One in which participants received an intervention, and one in which participants did not receive the intervention. The intervention consisted of two phases. Firstly, the elderly had a relatively short (10 to 20 minute) telephone call with a volunteer, once a week for a period of six weeks. After that, 12 weeks followed in which the elderly had group phone calls with up to six other participants which lasted an hour and were facilitated by a trained volunteer [39]. Unfortunately, although the study seemed to show improvements in both the health and mental health of the elderly, too many volunteers quit the intervention [39].
Thus, although telephone befriending could become a useful intervention for housebound elderly, it would be valuable for scientists to initiate more research on the effectiveness of the intervention in decreasing loneliness. Moreover, we should think about ways in which volunteers can be retained who do the telephone befriending, so that it may become an enjoyable or valuable experience not only for the elderly but also for the volunteers themselves. A fruitful solution could be to introduce a salary for this service and create jobs to realise telephone befriending in the long run.
Conclusion
While we have presented valuable steps to decrease loneliness according to the diverse cognitive and physical abilities of elderly, policymakers have to invest more money into this problem to – for example – avoid volunteers leaving the phone befriending programme after a while. Also, such interventions must be applied way more often, in nursing homes, but also for the general public since not all elderly people can afford residing in nursing homes. Finally, we have to create more awareness about this problem among policy makers and the general public to underline the importance of investing in interventions. We cannot simply ignore the rapidly ageing population and the increasing issue of loneliness among elderly. Rather, we need to build a society where older people are welcomed, integrated, respected and supported and not rejected as soon as they enter retirement. Loneliness represents only one of the challenges that come with an ageing population, but as we hopefully made clear in this longread it is a very important one which needs to be addressed. With this longread we hope to represent elderly as a group in society that deserves to be heard, cared for and to be integrated in our society, as this is exactly where they belong and have the right to be.
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